Erector spinae plane block versus its combination with superficial parasternal intercostal plane block for postoperative pain after cardiac surgery: a prospective, randomized, double-blind study

Burhan Dost, Cengiz Kaya, Esra Turunc, Hilal Dokmeci, Semih Murat Yucel, Deniz Karakaya, Burhan Dost, Cengiz Kaya, Esra Turunc, Hilal Dokmeci, Semih Murat Yucel, Deniz Karakaya

Abstract

Background: We aimed to compare the effectiveness of bilateral erector spinae plane (ESP) block and superficial parasternal intercostal plane (S-PIP) + ESP block in acute post-sternotomy pain following cardiac surgery.

Methods: Forty-seven patients aged between 18 and 80 years of age with American Society of Anesthesiologists class II-III due to undergo median sternotomy for cardiac surgery were included in this prospective, randomized, double-blinded study. Following randomization into two groups, one group received bilateral ultrasound-guided ESP and the other S-PIP plus ESP block. Morphine consumption within the first 24 h after surgery was the primary outcome of the study while NRS scores at rest, NRS scores when coughing, time taken until extubation, use of rescue analgesic, presence of nausea/vomiting, length of hospital and intensive care unit (ICU) stay, and patient satisfaction were secondary outcome measures.

Results: Morphine use up to 24 h following surgery was statistically significantly different between the ESP block and ESP + S-PIP block groups (18.63 ± 6.60 [15.84-21.41] mg/24 h vs 14.41 ± 5.38 [12.08-16.74] mg/24 h, p = 0.021). The ESP + S-PIP block group had considerably reduced pain scores compared to the ESP block group across all time points. Rescue analgesics were required in 21 (87.5%) patients in the ESP block group and seven (30.4%) in the ESP + S-PIP group (p < 0.001). PONV, length of stay in the ICU and hospital, and time to extubation were similar between groups.

Conclusions: In open cardiac surgery, the combination of ESP and S-PIP blocks lowers pain scores and postoperative morphine requirement of patients.

Trial registration: Clinicaltrials Registration No: NCT05191953, Registration Date: 14/01/2022.

Keywords: Acute; Cardiac; Median sternotomy; Nerve block; Postoperative pain; Surgical procedures; Ultrasonography.

Conflict of interest statement

None.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Schematic illustration of an ultrasound-guided erector spinae plane block
Fig. 2
Fig. 2
Schematic illustration of where to inject local anesthetic when using an ultrasound-guided superficial parasternal intercostal plane block. Purple highlighted area is the desired spread of local anesthetic
Fig. 3
Fig. 3
Flow diagram showing the distribution of patient data. Abbreviations: ESP, erector spinae plane; S-PIP, superficial parasternal intercostal plane
Fig. 4
Fig. 4
A, B Comparison of postoperative NRSrest and NRScoughing pain scores between the study groups at different time points. NRS values were significantly lower in ESP + S-PIP Block group than in ESP Block group at all time intervals postoperatively (p < 0.05). Abbreviations: NRS, numeric rating scale; ESP, erector spinae plane; S-PIP, superficial parasternal intercostal plane

References

    1. Huang APS, Sakata RK. Pain after sternotomy – review. Brazilian Journal of Anesthesiology (English Edition) 2016;66(4):395–401. doi: 10.1016/j.bjane.2014.09.013.
    1. Mazzeffi M, Khelemsky Y. Poststernotomy pain: a clinical review. J Cardiothorac Vasc Anesth. 2011;25(6):1163–1178. doi: 10.1053/j.jvca.2011.08.001.
    1. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621–627. doi: 10.1097/AAP.0000000000000451.
    1. Adhikary SD, Bernard S, Lopez H, Chin KJ. Erector Spinae Plane Block Versus Retrolaminar Block: A Magnetic Resonance Imaging and Anatomical Study. Reg Anesth Pain Med. 2018;43(7):756–762.
    1. Yang HM, Choi YJ, Kwon HJ. O J, Cho TH, Kim SH: Comparison of injectate spread and nerve involvement between retrolaminar and erector spinae plane blocks in the thoracic region: a cadaveric study. Anaesthesia. 2018;73(10):1244–1250. doi: 10.1111/anae.14408.
    1. Tsui BCH, Navaratnam M, Boltz G, Maeda K, Caruso TJ. Bilateral automatized intermittent bolus erector spinae plane analgesic blocks for sternotomy in a cardiac patient who underwent cardiopulmonary bypass: A new era of Cardiac Regional Anesthesia. J Clin Anesth. 2018;48:9–10. doi: 10.1016/j.jclinane.2018.04.005.
    1. Macaire P, Ho N, Nguyen T, Nguyen B, Vu V, Quach C, Roques V, Capdevila X. Ultrasound-Guided Continuous Thoracic Erector Spinae Plane Block Within an Enhanced Recovery Program Is Associated with Decreased Opioid Consumption and Improved Patient Postoperative Rehabilitation After Open Cardiac Surgery-A Patient-Matched, Controlled Before-and-After Study. J Cardiothorac Vasc Anesth. 2019;33(6):1659–1667. doi: 10.1053/j.jvca.2018.11.021.
    1. Krishna SN, Chauhan S, Bhoi D, Kaushal B, Hasija S, Sangdup T, Bisoi AK. Bilateral Erector Spinae Plane Block for Acute Post-Surgical Pain in Adult Cardiac Surgical Patients: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth. 2019;33(2):368–375. doi: 10.1053/j.jvca.2018.05.050.
    1. Saadawi M, Layera S, Aliste J, Bravo D, Leurcharusmee P, Tran DQ. Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks. J Clin Anesth. 2021;68:110063. doi: 10.1016/j.jclinane.2020.110063.
    1. Tulgar S, Ahiskalioglu A, De Cassai A, Gurkan Y. Efficacy of bilateral erector spinae plane block in the management of pain: current insights. J Pain Res. 2019;12:2597. doi: 10.2147/JPR.S182128.
    1. Taketa Y, Irisawa Y, Fujitani T. Comparison of ultrasound-guided erector spinae plane block and thoracic paravertebral block for postoperative analgesia after video-assisted thoracic surgery: a randomized controlled non-inferiority clinical trial. Reg Anesth Pain Med. 2020;45(1):10–15. doi: 10.1136/rapm-2019-100827.
    1. de la Torre PA, García PD, Álvarez SL, Miguel FJG, Pérez MF. A Novel Ultrasound-Guided Block: A Promising Alternative for Breast Analgesia. Aesthetic Surg J. 2014;34(1):198–200. doi: 10.1177/1090820X13515902.
    1. Schulz KF, Altman DG, Moher D. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMC Med. 2010;8:18. doi: 10.1186/1741-7015-8-18.
    1. Dost B, Kaya C, Ozdemir E, Ustun YB, Koksal E, Bilgin S, Bostancı Y. Ultrasound-guided erector spinae plane block for postoperative analgesia in patients undergoing open radical prostatectomy: A randomized, placebo-controlled trial. J Clin Anesth. 2021;72:110277. doi: 10.1016/j.jclinane.2021.110277.
    1. Kaya C, Dost B, Dokmeci O, Yucel SM, Karakaya D: Comparison of Ultrasound-Guided Pectointercostal Fascial Block and Transversus Thoracic Muscle Plane Block for Acute Poststernotomy Pain Management After Cardiac Surgery: A Prospective, Randomized, Double-Blind Pilot Study. J Cardiothorac Vasc Anesth 2021.
    1. Erden S, Karadağ M, Güler Demir S, Atasayar S, Opak Yücel B, Kalkan N, Erdoğan Z, Ay A. Cross-cultural adaptation, validity, and reliability of the Turkish version of revised American Pain Society patient outcome questionnaire for surgical patients. Agri. 2018;30(2):39–50.
    1. Athar M, Parveen S, Yadav M, Siddiqui OA, Nasreen F, Ali S, Haseen MA. A Randomized Double-Blind Controlled Trial to Assess the Efficacy of Ultrasound-Guided Erector Spinae Plane Block in Cardiac Surgery. J Cardiothorac Vasc Anesth. 2021;35(12):3574–3580. doi: 10.1053/j.jvca.2021.03.009.
    1. Karacaer F, Biricik E, Ilgınel M, Tunay D, Topçuoğlu Ş, Ünlügenç H. Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized, controlled study. J Clin Anesth. 2022;80:110797. doi: 10.1016/j.jclinane.2022.110797.
    1. Ersoy BBG, Tuna E, Aysin: Postoperative analgesic effectiveness of bilateral erector spinae plane block for adult cardiac surgery: a randomized controlled trial. 5 2022.
    1. Li J, Lin L, Peng J, He S, Wen Y, Zhang M: Efficacy of ultrasound-guided parasternal block in adult cardiac surgery: a meta-analysis of randomized controlled trials. Minerva Anestesiol 2022.
    1. Laigaard J, Pedersen C, Rønsbo TN, Mathiesen O, Karlsen APH. Minimal clinically important differences in randomised clinical trials on pain management after total hip and knee arthroplasty: a systematic review. Br J Anaesth. 2021;126(5):1029–1037. doi: 10.1016/j.bja.2021.01.021.
    1. Muñoz-Leyva F, El-Boghdadly K, Chan V. Is the minimal clinically important difference (MCID) in acute pain a good measure of analgesic efficacy in regional anesthesia? Reg Anesth Pain Med. 2020;45(12):1000–1005. doi: 10.1136/rapm-2020-101670.
    1. Chin KJ, El-Boghdadly K. Mechanisms of action of the erector spinae plane (ESP) block: a narrative review. Can J Anaesth. 2021;68(3):387–408. doi: 10.1007/s12630-020-01875-2.
    1. Selvi O, Tulgar S, Serifsoy TE, Lance R, Thomas DT, Gürkan Y. Quadrant and Dermatomal Analysis of Sensorial Block in Ultrasound- Guided Erector Spinae Plane Block. Eurasian J Med. 2022;54(2):121–126. doi: 10.5152/eurasianjmed.2022.21151.
    1. Taketa Y, Irisawa Y, Fujitani T. Ultrasound-guided erector spinae plane block elicits sensory loss around the lateral, but not the parasternal, portion of the thorax. J Clin Anesth. 2018;47:84–85. doi: 10.1016/j.jclinane.2018.03.023.
    1. Khera T, Murugappan KR, Leibowitz A, Bareli N, Shankar P, Gilleland S, Wilson K, Oren-Grinberg A, Novack V, Venkatachalam S, et al. Ultrasound-Guided Pecto-Intercostal Fascial Block for Postoperative Pain Management in Cardiac Surgery: A Prospective, Randomized. Placebo-Controlled Trial J Cardiothorac Vasc Anesth. 2021;35(3):896–903. doi: 10.1053/j.jvca.2020.07.058.
    1. Kumar AK, Chauhan S, Bhoi D, Kaushal B. Pectointercostal Fascial Block (PIFB) as a Novel Technique for Postoperative Pain Management in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth. 2021;35(1):116–122. doi: 10.1053/j.jvca.2020.07.074.
    1. Bousquet P, Labaste F, Gobin J, Marcheix B, Minville V. Bilateral Parasternal Block and Bilateral Erector Spinae Plane Block Reduce Opioid Consumption in During Cardiac Surgery. J Cardiothorac Vasc Anesth. 2021;35(4):1249–1250. doi: 10.1053/j.jvca.2020.07.021.
    1. De Cassai A, Geraldini F, Carere A, Sergi M, Munari M. Complications Rate Estimation After Thoracic Erector Spinae Plane Block. J Cardiothorac Vasc Anesth. 2021;35(10):3142–3143. doi: 10.1053/j.jvca.2021.02.043.

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